Regional MCNs for HIV

Transcription

1 Meeting: IPG Date: 3 rd September 2009 Item: NORTH OF SCOTLAND PLANNING GROUP Regional MCNs for HIV This paper sets out the proposal to establish three regional MCNs for HIV and requests support from regional planning groups. Background The Sexual Health and HIV Team within the Scottish Government are currently developing an HIV Action Plan (see appendix 1). This plan has been developed to address the rise in new diagnosis of HIV and to improve the co ordination of prevention activities, treatment and care. It is intended that the Action Plan will facilitate a refocus on HIV in Scotland and provide a co ordinated, national response. There were 453 newly diagnosed HIV infected persons reported in Various national organisations have been designated as responsible bodies. In addition, NHS Boards will have an essential role in taking the Action Plan forward and addressing the co ordination, accessibility and accountability of their services. Proposal Action One of the HIV Action Plan is to establish three regional Managed Prevention and Care Networks, an adaptation of the traditional MCN, to reflect the importance in addressing HIV. These regional MPCNs are seen as central to the Action Plan and to its effective and long term implementation. It is proposed that the regional MPCNs would provide a mechanism whereby smaller boards can work in partnership with those larger boards and allow the sharing of best practice and expertise. The networks will have a role in helping the boards provide the prevention services that are required to address HIV transmission and rising numbers of diagnoses, through needs assessment for example. In addressing prevention effectively, it is intended that treatment and care costs could be reduced in future. Health Protection Scotland (HPS) will provide Programme Management for the Action Plan and this will include supporting the MPCN Regional Co ordinators. HPS will monitor and report progress to Scottish Government. Networks will be funded by the Scottish Government for 18 months. The Sexual Health and HIV Team are looking for the support of the Regional Planning Groups in setting up these networks and ensuring their long term sustainability. The proposed launch date is September Discussion It is not clear why a regional approach has been recommended and it should be noted that NHS Tayside have been included in the East regional network. There has to date, been no discussion with regional planning groups before recommending such an approach. Replies to the questions posed by the West of Scotland Regional Planning Group are attached at appendix 1. Members are asked to consider whether this proposal should be supported. Sandra Hay Corporate Services Manager North of Scotland Planning Group North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles

2 Questions posed by the West of Scotland Regional Planning Group Appendix 1 1. What debate has taken place with local Boards re the proposed regional networks and what is the rational for 3 regional networks as opposed to one national one? The boards have been involved in the discussion around the proposed regional networks and this has been a long standing element of the plan. Both clinicians and public health colleagues have been involved in the development of the plan on a board by board basis. The regional approach has been identified as being particularly appropriate to HIV. The regional MPCNs would provide a mechanism whereby smaller boards can work in partnership with those larger boards and allow the sharing of best practice, expertise etc. The networks will have an essential role in helping the boards to provide the prevention services that are required to address HIV transmission and rising numbers of diagnoses, through the needs assessment for example. In addressing prevention effectively it is intended that treatment and care costs could be reduced in the future. There are differences across Scotland in the way that HIV prevention and treatment and care activities are addressed. A regional approach means that the regional co ordinators can tackle issues specifically and appropriately. 2. What is the recurring funding support for the action plan including the networks? The Scottish Government has committed to funding specific parts of the plan, and this includes the MPCNs. We are able to fund the networks for 18 months. We are also funding a social marketing campaign for men who have sex with men (MSM) and the HPS programme management. 3. How does the action plan relate to other resources eg blood borne virus? Action 12 of the Action Plan looks to Boards to report on the existing budget spend of the BBV Prevention budget. The BBV Prevention budget is ring fenced, however we are aware that some Boards aren t using this money for BBV Prevention. The BBV Prevention money should be used by Boards for prevention activities and Boards should be making use of this money for HIV prevention activities as part of implementing the Action Plan. 4. What are the governance arrangements surrounding this set of proposals? As stated in Action 13, Health Protection Scotland are providing Programme Management for the HIV Action Plan. This will include supporting the MPCN Regional Co ordinators but includes the monitoring of all of the actions in the plan. HPS will inform the Scottish Government of progress and work with all the lead organisations. The MPCNs and the lead organisations will report to the HIV Action Plan Governance Group (see page 20 of the plan) 5. What discussion has taken place with Derek Feeley and his team around this Action Planit would be helpful to have their input to any proposed change in planning arrangements Will Scott and Craig Bell in Healthcare Planning are aware of the plan and had suggested that contact be made with the Regional Planning Directors to discuss support in sustaining the Regional MPCNs in the long term. 6. If no recurring resource is available to support the MCNs there would need to be further debate about the relative priority of this development in the light of other regional proposals. In the West of Scotland we have a structured regional resource prioritisation process and would need to consider these proposals as part of this process. As mentioned previously, the Scottish Government has funding to support the three regional networks for 18 months and HPS will support them practically in set up and implementation. There were 453 newly diagnosed HIV infected persons reported in The HIV Action Plan will be instrumental in tackling a reduction in HIV transmission, through supporting widespread HIV prevention activities and the sharing of best practice within and between regions. North of Scotland Planning Group is a collaboration between NHS Grampian, NHS Highland, NHS Orkney, NHS Shetland, NHS Tayside and NHS Western Isles

3 Appendix 2 HIV Action Plan in Scotland September 2009 to March 2014 Draft: Final Draft 10 August

4 HIV Action Plan in Scotland September 2009 to March 2014 Contents Ministerial Foreword Acknowledgements Process of Action Plan Development Summary of Actions Section One: Section Two: Introduction Specific Issues, Actions and Responsibilities References Appendix One:Glossary of terms Appendix Two: HIV Action Plan Group Membership Appendix Three: Proposed HIV Accountability Structures Appendix Four: Action Plan Responsibilities 4

5 Ministerial Foreword 5

6 Acknowledgements Process of Action Plan Development 6

7 Summary of Actions Ensuring effective co ordination of prevention, care and treatment Action 1 Three regional Managed Prevention and Care Networks (MPCNs) for HIV will be established in Scotland. Action 2 Standards for HIV Prevention, Diagnosis, Treatment and Care will be developed and implemented. Action 3 A generic patient management system (PMS) involving Scotland s principal HIV Treatment Centres will be investigated and, if appropriate, developed and implemented. Action 4 Regional MPCN plans will be introduced indicating measures to assess local need, maintain and improve treatment and care services and prevention initiatives related to HIV testing. Action 5 The potential for the block purchasing of anti retroviral therapy (ART) to reduce cost will be assessed. Action 6 An investigation into the reasons why some people living with HIV do not attend specialist services will be undertaken. Reducing levels of undiagnosed HIV and transmission in Scotland Action 7 Systems to monitor risk behaviours and new HIV infections among persons at highest risk of acquiring infection will be reviewed, developed and implemented. Action 8 The development and implementation of social marketing materials for MSM. Action 9 Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in MSM. Guidance will be implemented at the local and national level, where appropriate. Action 10 Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in persons originating from areas high prevalence, particularly African countries. Guidance will be implemented at the local and national level, where appropriate. Action 11 Educational programmes for the HIV related workforce and Primary Care will be developed and implemented. 7

8 Effective Monitoring of HIV Resources and Improved Accountability Action 12 Scottish Government will review existing budget spend and produce guidance on the recommended future spend of BBV budgets. NHS Boards will provide information on current and proposed future annual spend of the BBV Prevention budget against local priorities. Action 13 A National Programme Management approach will be employed to support the MPCNs. The Scottish Government, NHS Special Boards and other national agencies are responsible for delivering identified actions. 8

9 Section One: Introduction HIV is a major public health challenge for Scotland. More people are living with HIV in Scotland than ever before as a result of increased testing, leading to earlier diagnosis, particularly in genitourinary medicine (GUM) clinic settings and more effective management of those living with HIV. In addition, by 2012, the number of people living with HIV and requiring specialist care is likely to increase by 5 13% (some persons) per year 1 and the average age of individuals living with HIV will increase over time as effective drug regimens sustain and improve their quality of life. Providing treatment and care for all those who require it is one of Scotland s most pressing HIV challenges 2. Despite record numbers of new diagnoses in recent years (see HIV Action Plan Epidemiology supporting paper) principally as a result of the Respect and Responsibility 3 opt out HIV testing policy, there is evidence of: (i) transmission of infection; (ii) undiagnosed infection; and, (iii) high risk behaviour in certain groups of the population (4,5,6,7). Thus, effective, evidence informed HIV prevention is key to reducing the risks of HIV acquisition. Whilst HIV was included in the wider context of the actions under Respect and Responsibility 3, Scotland s first sexual health strategy, it has lost some of its priority focus at both national and local level. This has resulted in inconsistent responses to HIV prevention and mixed models of care across Scotland. In response, this Action Plan builds on the draft proposals developed by the multi agency HIV Action Plan Group, the Treatment and Care Needs Assessment commissioned by the Scottish Government and produced by the Scottish Public Health Network (ScotPHN) and the extensive feedback received from key stakeholders and individuals, including those living with HIV. This Action Plan addresses the need for refocused action across Scotland in response to these issues. The overarching aims are to: Improve the effective co ordination of prevention and treatment and care activities across health, social care and voluntary sectors Reduce levels of HIV transmission and undiagnosed HIV Develop appropriate accountability and reporting arrangements together with increased opportunities to evaluate and research practice. This Action Plan will facilitate the co ordination and pursuit of best practice in prevention and models of care across Scotland. It aims to overcome organisational and professional silos to ensure effective co ordination and, where necessary, re design services to improve effectiveness and efficiency. An integrated approach which includes harnessing the distinct and valuable contributions of both the voluntary and statutory sector is core to this Action Plan. Lessons have been learned from the development and implementation of other strategies such as the Hepatitis C Phase II Action Plan for Scotland. 8 The associated increase in resources for its implementation has set a template for how the NHS in Scotland can respond to infectious diseases. This has highlighted the value that could come from adopting a similar approach albeit with more modest funding for HIV. 9

10 This document is a practical plan highlighting what must happen and who must be involved if the overall aims are to be achieved through: Integrating HIV prevention and treatment and care. Reducing HIV transmission and undiagnosed HIV through social marketing, education, service provision and guidance; and Improving performance management and accountability. 10

11 Section Two: Specific Issues, Actions and Responsibilities ISSUE Prevention, Diagnosis, Treatment and Care: Improved co ordination of HIV services, standards and guidelines. Effective links between prevention and treatment and care are crucial in the management of HIV. Improving access to, and the provision of, diagnostic and treatment and care services can contribute to a reduction in the transmission of HIV and a longer survival time for those living with HIV 9. Treatment and care services for HIV infected persons in Scotland, generally, are of a very high standard but, in the context of the ever increasing complexity of managing an aging, multi ethnic, urban centric and rapidly growing cohort, some inconsistencies in access to and provision of optimal services are evident across NHS Boards 1. The lessons learned from the measures taken to reduce HIV transmission among injecting drug users and between HIV positive mothers and their babies should be translated to support access to and the provision of HIV diagnostic and prevention services for MSM and persons originating from areas high prevalence, particularly African countries. The sexual health needs of people living with HIV should be seen as an integral part of their HIV treatment and care. The application of the NHS Quality Improvement Scotland (QIS) standard on sexual healthcare for people with HIV should ensure this need is met. When undertaken effectively, HIV prevention activities, such as exploring social and sexual cultures, disclosure of HIV status, condom use and availability, concentrate on influencing sexual attitudes, values and behaviour. This requires co ordinated efforts across health, social care and voluntary sectors in both sexual health and HIV specific services. The great majority of those infected or at high risk of infection reside in Scotland s largest urban areas, particularly within the Greater Glasgow and Lothian NHS Boards. The Action Plan, through establishing three regional Managed Prevention and Care Networks (MPCNs), will help support those NHS Boards who have smaller numbers of persons in high risk groups to more effectively address their needs. Managed Prevention and Care Networks (MPCNs) Forthcoming guidance from the Scottish Government will inform the establishment of three regional Managed Prevention and Care Networks (MPCNs) East for Lothian, Fife, Borders and Tayside West for Greater Glasgow and Clyde, Dumfries and Galloway, Ayrshire and Arran, Forth Valley and Lanarkshire North for Grampian, Highland, Western Isles, Orkney and Shetland 11

12 All MPCNs Will be co chaired by clinical and public health specialists and will include, amongst others, representatives from Local Authority and Social Care, Mental Health, Voluntary, Dentistry, Scottish Prison Service, General Practice, Paediatric and service user sectors. Will be responsible for supporting and monitoring NHS Boards in their implementation of guidelines and other Best Practice approaches to testing, treatment, prevention, care and support. * Will access the support of statutory and voluntary organisations as appropriate and will facilitate multiagency and professional disciplinary working at local, regional and national levels: for example, through supporting a national network of individuals involved in the care of infected young people. Will support the development and implementation of specific NHS QIS standards for HIV prevention, diagnosis, treatment and care, along with (subject to available funding) a generic patient management system (PMS). These developments will both support the future accreditation of the MPCNs and ensure equitable and optimal patient support in Scotland. Action 1 Three regional Managed Prevention and Care Networks (MPCNs) for HIV will be established in Scotland. Action 2 Standards for HIV Prevention, Diagnosis, Treatment and Care will be developed and implemented. Action 3 A generic patient management system (PMS) involving Scotland s principal HIV Treatment centres will be investigated and, where appropriate, developed and implemented. Outcome These actions will, by improving the co ordination and effectiveness of monitoring of activities, ensure that Prevention, Diagnosis, Treatment and Care service provision for HIV infected persons and those at high risk of acquiring infection throughout Scotland are optimal and equitable. * Such as those recommended by the MSM Subgroup of NSHAC (Clutterbuck, 2008), from the British HIV Association ( the National Institute of Clinical Excellence ( the Expert Advisory Group on AIDS ( and the British Association of Sexual Health and HIV ( 12

13 ISSUE Prevention, Diagnosis, Treatment & Care: Improved planning of HIV services and reducing the cost of antiretroviral therapy (ART) By 2012, the number of people living with HIV and requiring specialist care is likely to increase by 5 13% (some persons) per year 1 and the average age of individuals living with HIV will increase over time as effective drug regimens sustain and improve their quality of life. Evidence indicating the benefits of early initiation of ART is likely to lead to an increase in the number of persons requiring therapy in the long term. The impact of these changes in terms of therapeutic and care costs is likely to be considerable and NHS Boards should endeavour to plan for this likely increase. Prevention activities across Scotland can be inconsistent and in some instances are neither evidence informed nor targeted at those who are most at risk of infection 10. NHS boards should undertake or update a needs assessment, which includes service mapping and HIV prevention activities, for those at greatest risk of HIV infection and those living with HIV to inform regional clinical planning. It is essential that planning for also includes detail on the resources, including costs, required to address the needs of people living with HIV. Needs assessments should take into account increases in HIV testing and the prevention of onward transmission and should also consider underlying factors such as the issues of stigma, mental health and wellbeing, homophobia, racism, substance use and cultural influences/belief systems. These actions must lead to an increase in uptake of HIV testing, in particular, among MSM and persons originating from high prevalence, particularly African countries, and a lowering in the numbers who remain undiagnosed. A further opportunity to reduce the cost of HIV treatment will be assessed through improved procurement of ART. By block purchasing such drug treatments, savings can be made to ensure that the above increased supply is at least in part anticipated. Action 4 Regional MPCN plans indicating measures to maintain and, where appropriate, improve treatment and care and prevention services will be developed and implemented Action 5 The potential for the block purchasing of anti retroviral therapy (ART) to reduce cost will be assessed. Outcome These actions will enable NHS Boards to understand the resources and developments required to address the current inconsistencies in HIV prevention activities across Scotland and the needs of people living with HIV. The implementation of these actions will promote the optimal treatment and care of such individuals and will also lead to a potential reduction in the cost of ART for NHS Boards. 13

14 ISSUE Treatment & Care: Improved access to specialist HIV care Many factors influence the engagement of people living with HIV with both clinical and support and care services. A significant number of infected persons (upwards of 1,000 individuals) diagnosed in Scotland have not entered or have defaulted from, specialist care services. The reasons for this and how they might be addressed are unclear. An investigation by statutory and voluntary organisations on the individuals who have engaged for diagnosis, support and care but not for treatment and clinical follow up is required. Action 6 An investigation into the reasons why some people living with HIV do not attend specialist clinical services will be undertaken. Outcome The findings of the investigation will determine how to attract and retain in specialist clinical care those individuals who do not currently access services. ISSUE Improving HIV transmission and risk behaviour surveillance Existing surveillance systems involving MSM and persons from areas of higher prevalence, particularly African countries, are limited in terms of geographical coverage, accurate detection and/or estimation of new HIV transmissions and the ability to evaluate the impact of interventions designed to prevent high risk behaviour and HIV infection. Existing systems should be reviewed and where necessary further developed. New systems, including the potential application of sophisticated laboratory tests to, for example, identify the recency of infection among new diagnoses, should be established, if required. Action 7 Systems to monitor risk behaviours and new HIV infections among persons at highest risk of acquiring infection will be reviewed and, if appropriate, developed and implemented. Outcome This action will lead to an improved understanding of the epidemiology of HIV transmission and HIV related behaviour. These data will inform the planning of services and the development of guidance (See Actions 4 and 9 10). 14

15 ISSUE Preventing HIV Transmission among MSM and persons originating from high prevalence, particularly African countries. Given that HIV disproportionately affects key groups of people it is essential that prevention activities are focussed where they are most likely to have the highest impact in reducing HIV transmission and improving HIV related sexual health. Accordingly, in Scotland, such activities will focus on All persons living with HIV MSM Persons originating from high prevalence, particularly African countries. From data currently available, it is evident that HIV transmission is occurring in Scotland particularly among the MSM community; in 2007, 58% of MSM reported that they had probably acquired their infection in Scotland. In contrast, 12% of heterosexually acquired infection was presumed to have been acquired in Scotland the majority of heterosexually acquired infection is among those who acquired their infection in high prevalence areas, particularly in Africa. (See HIV Action Plan Epidemiology supporting paper) To raise awareness of HIV and support future interventions which target MSM, social marketing materials will be developed. This targeted work is being delivered in the context of wider action in the Respect & Responsibility programme to improve HIV awareness among the general population. Guidance and advice on preventing and reducing the transmission of HIV among MSM are available. Expertise in Scotland exists to review this guidance and to also inform the development of new guidance. Guidance produced will provide advice for MPCNs on how to work to prevent further transmission of HIV among both MSM and persons originating from high prevalence, particularly African countries, in Scotland. The MPCNs can tailor interventions to reflect local circumstances. Action 8 The development and implementation of social marketing materials for MSM. Action 9 Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in MSM. Guidance will be implemented at the local and national level, where appropriate. Examples include BASHH Guidance, BHIVA Guidelines ( the recommendations of the MSM subgroup of NSHAC, Making It Count (Hickson et al, 2003) and forthcoming NICE Guidance ( March 2011) 15

16 Action 10 Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in persons originating from areas of high prevalence, particularly African countries. Guidance will be implemented at the local and national level, where appropriate. Outcome These actions will result in increased awareness of existing and future evidence and guidance which will contribute to a reduction in the rate of new transmission of HIV among MSM and persons from areas of high prevalence, particularly African countries. ISSUE Improving Education and HIV Awareness Raising The landscape of knowledge and guidance concerning interventions associated with the prevention, diagnosis and treatment and care of people living with HIV is changing constantly. Due to ART, people with HIV are living longer, resulting in more complex health needs. It is important, therefore, to ensure that gaps in knowledge among the HIV related workforce, including primary care teams responsible for managing non HIV related conditions in HIV infected and sexually active persons, are addressed. This action is also intended to strengthen related activity within Respect and Responsibility Staff should be informed and updated through regular training and knowledge events. These events must: Ensure familiarity with MSM and African specific issues Demonstrate commitment to equality and diversity Prioritise personnel working in areas such as the general practice setting. This should also be informed by needs assessment, existing training initiatives and accredited training programmes. Action 11 Educational programmes for the HIV related workforce and Primary Care will be developed and implemented. Young people, particularly those at risk of HIV infection, such as young MSM, also need to be informed and updated on risks associated with HIV transmission. Schools, further education, community and other settings which engage with vulnerable young people must input into the development of guidance and support materials and deliver these as part of the commitments to the Respect & Responsibility programme. 11 Outcome 16

17 These actions will lead to the wider population, those at particular risk of infection and the HIV related workforce being informed, as appropriate, about current HIV knowledge, guidance and service availability. They will not substitute for the tailored and individual interventions which many at increased risk of HIV will require (see Actions 8 10). ISSUE HIV Resources within BBV Prevention budgets; monitoring and accountability. Many NHS Boards have been using their BBV Prevention budgets for HIV testing purposes. Greater recognition of the importance of diagnosing BBV, particularly HIV, infection in helping to prevent its onward transmission is required. Action 12 Scottish Government will review existing budget spend and produce guidance on the recommended future spend of BBV budgets. NHS Boards will provide information on current and proposed future annual spend of the BBV Prevention budget against local priorities. Outcome Improved budgetary accountability will lead to a more efficient use of funding. ISSUE Improving National and Regional/Local Co ordination To ensure that the actions are delivered efficiently, effectively, to timescale and are governed appropriately, national and local accountability structures will be developed. An HIV Action Plan Governance Board (APGB), comprising of the clinical and public health leads of the regional MPCNs and representatives of national agencies responsible for delivering the Action Plan will be established. NHS Boards will be directly accountable to the Scottish Government for the delivery of the Plan but will report to the HIV APGB via the MPCNs. Action 13 A National Programme Management approach will be employed to support the MPCNs. The Scottish Government, NHS Special Boards and other national agencies are responsible for delivering identified actions. Outcome Accountability structures will ensure the actions are delivered efficiently, effectively and to timescale. 17

18 References 1. Johnman, C. (2009) Treatment and Care Needs Assessment: People Living with HIV. Scottish Public Health Network (ScotPHN) 2. FOCUS: HIV in Scotland, 2008: Review. HPS Weekly Report, 4 th February 2009 Vol. 43 No.2009/ Scottish Executive, Respect and Responsibility: A Strategy and Action Plan for Sexual Health. Scottish Executive, Available from: 4. FOCUS 2: Unlinked anonymous HIV testing of genitourinary medicine clinic attendees in Glasgow: HPS Weekly Report 2008; 42 (47): Available at 5. FOCUS: HIV among pregnant women in Scotland data to HPS Weekly Report 2008; 42 (16): Sexually Transmitted Infection Epidemiology Advisory Group. Scotland s Sexual Health Information Health Protection Scotland and Information Services Division, November Williamson, L.M., Hart, G.J. (2007) HIV prevalence and undiagnosed infection among a community sample of gay men in Scotland, UK. Journal of Acquired Immune Deficiency Syndromes; 45: Scottish Government. Hepatitis C Action Plan for Scotland: Phase II (May 2008 March 2011). Edinburgh. Scottish Government; Available from: 9. Lancet Global Health Network (2008), HIV Prevention Series (Launched August, 2008) Available from: Burtney, L., Hosie, A. (2007) HIV and Sexual Health Promotion Activities for Gay and Bisexual Men and Black and Minority Ethnic/African Communities in Scotland. HIV Scotland. 11. Scottish Government. Respect and Responsibility Available from: 18

19 HIV Action Plan also informed by 1. Global HIV Prevention Working Group (2008) Behaviour Change and HIV Prevention: [Re] Considerations for the 21 st Century. Available from: 2. Goldberg, D. (2008) TBC 3. Scottish Government, Chief Medical Officer Directorate: CEL 15 (2007), 23 October 2007 Available at: 4. UNAIDS (2007) Practical Guidelines for Intensifying HIV Prevention, Towards Universal Access, Available from: ds_universal_access_en.pdf 5. Herbst, J.H., Beeker, C, Matthew, A., McNally, T., Passin, W.F., Kay, L.S., Crepaz, N., Lyles, C.M., Briss, P., Chattopadhyay, S., Johnson, R.L., Task Force on Community Prevention Studies. (2007) The effectiveness of individual, group, and community level HIV behavioural risk reduction interventions for adult men who have sex with men: a systematic review. American Journal of Preventative Medicine; 32: S Phillips, A.N. et al. (2007) When should antiretroviral therapy for HIV be started? BMJ 334: FOCUS 2: Unlinked anonymous HIV testing of genitourinary medicine clinic attendees in Glasgow: HPS Weekly Report 2008; 42 (47): Available at 8. Goldberg, D. and Logan, L. (2005) Unlinked anonymous testing indicates antenatal HIV testing in England and Scotland is being successfully implemented. Eurosurveillance Weekly 10 (20). 9. Williamson, L.M., Dodds, J.P., Mercey, D.E., Hart, G.J., Johnson, A.M. (2008) Sexual risk behaviour and knowledge of HIV status among community samples of gay men in the UK. AIDS; 22(9): Health Protection Agency: Sexually transmitted infections in black African and black Caribbean communities in the UK: 2008 report. Available from: BHIVA, BASHH, BIS (2008) UK National Guidelines for HIV Testing 2008, Available from: Clutterbuck, D (2008) MSM Subgroup NSHAC 11: HIV Prevention, Report and Recommendations. 19

20 Glossary of Terms Appendix One AIDS APGB ART BASHH BBV BHIVA CD4 CMO GUM HIV HPS ID IDU Incidence NHS NSHAC (Now NSHHAC) Prevalence MedFASH MPCN MRC Mortality MSM NICE Respect & Responsibility ScotPHN SHIVAG Commercial gay scene STI UAI UNAIDS Acquired Immunodeficiency Syndrome Action Plan Governance Board Anti Retroviral Therapy British Association of Sexual Health & HIV Blood Borne Virus British Human Immunodeficiency Virus Association Cluster of Differentiation 4 (a glycoprotein expressed on the surface of T helper cells which is important in assessing the immune system of people with HIV) Chief Medical Officer for Scotland Genitourinary medicine Human Immunodeficiency Virus Health Protection Scotland Infectious diseases Intravenous Drug User Number of new cases in the population over a given time National Health Service National Sexual Health (and HIV) Advisory Committee Total number of cases in the population at a given time Medical Foundation for AIDS and Sexual Health Managed Prevention and Care Network Medical Research Council Death Men who have sex with men National Institute for Health and Clinical Excellence Scottish Government s action plan to improve sexual health. Scottish Public Health Network Scottish HIV and AIDS Group The commercial side (bars, pubs, clubs, saunas, gyms and sex shops) of gay life in Scotland. Sexually transmitted infection Unprotected Anal Intercourse Joint United Nations Programme on HIV & AIDS 20

21 HIV Action Plan Group Membership Appendix Two Membership Chair Mary Cuthbert, Head, Scottish Government Sexual Health and HIV Team Members external Gordon Scott David Goldberg Lesley Wallace Roy Kilpatrick Shirley Fraser Dan Clutterbuck Syed Ahmed Sheila Cameron Bruce Fraser Martha Baillie Lisa McDaid Ewen Stewart Rak Nandwani Nick Kennedy Gordon McKenna Paul Flowers Ailsa Spindler Iain Ramsay Nicky Coia John Logan Jim Sherval From January 2009 Ray Fox Gwyneth Jones Ian Robertson From May 2009 Phil Eaglesham Nicola Rowan Members Internal Dona Milne Cheryl Paris SHIVAG Health Protection Scotland Health Protection Scotland HIV Scotland NHS Health Scotland NHS Borders, Chair of NSHAC MSM sub group NHS Greater Glasgow and Clyde BBV Co ordinator NHS Greater Glasgow and Clyde Laboratories representative Gay Men s Health Waverley Care Medical Research Council Social and Public Health Sciences Unit Royal College of General Practitioners CMO Specialist Advisor in GUM NHS Lanarkshire ID Consultant NHS Highland GUM Consultant Glasgow Caledonian University Terrence Higgins Trust Learning Teaching Scotland NHS Greater Glasgow and Clyde NHS Lanarkshire NHS Lothian NHS Greater Glasgow and Clyde ID Consultant NHS Dumfries and Galloway ID Consultant BBV Practitioner Forum NHS Health Scotland Health Protection Scotland Scottish Government Sexual Health and HIV team Scottish Government Sexual Health and HIV team 21

22 Proposed HIV Action Plan Accountability Structure Chief Medical Officer Appendix Three Scottish Government Public Health Policy HIV Action Plan Governance Board Financial Accountability & Reporting Programme Management Team Financial Accountability & Reporting NHS Boards (Designated HIV leads) MPCNs (Public Health and Clinical Leads) National Organisations with Lead Responsibility 22

23 Appendix Four: HIV Action Plan Responsibilities Action Lead Responsibility Other Key Agencies Performance Indicators Short Term Medium Term Long Term Outcomes 1. Three regional Managed Prevention and Care Networks (MPCNs) for HIV will be established in Scotland. 2. Standards for HIV Prevention, Diagnosis, Treatment and Care will be developed and implemented. 3. A generic patient management system (PMS) involving Scotland s principal HIV Treatment Centres will be investigated and, if appropriate, developed and implemented. HIV Leads Quality Improvement Scotland. NHS National Services Scotland (NSS) National Information Systems Group Quality Improvement Scotland (Accreditation of MPCNs). Health Protection Scotland Scottish Government NHS Health Scotland National organisations identified in this HIV Action Plan. The regional MPCNs. Scottish Government The regional MPCNs. Quality Improvement Scotland Accreditation of MPCNs (Linked through Action Plan Governance Board) NHS QIS Standards for HIV Prevention, Diagnosis, Treatment and Care Guidance on MPCN establishment issued by Scottish Government by October Outline business case developed and submitted to e Health at Scottish Government by Dec MPCN clinical and public health leads and co ordinators appointed by April Standards developed and published by December Subject to approval by e Health, an outline business case then submitted to NSS. MPCN s steering groups established and first meeting to have taken place by July MPCNs fully accredited by December Subject to approval and agreed funding, Patient Management System developed and implemented by December 2012 and implemented thereafter. These Actions will, by improving the co ordination and effectiveness of monitoring of activities, ensure that Prevention, Diagnosis, Treatment and Care service provision for HIV infected persons and those at highrisk of acquiring infection throughout Scotland are optimal and equitable. 23

24 Action Lead Responsibility Other Key Agencies Performance Indicators Short Term Medium Term Long Term Outcomes 4. Regional MPCN plans indicating measures to maintain and, where appropriate, improve treatment/care and prevention services will be developed and implemented 5. The potential for the block purchasing of antiretroviral therapy (ART) to reduce cost will be assessed. MPCN clinical and public health leads National Procurement. The regional MPCNs. NHS Health Scotland HIV Scotland in their role as representative of the HIV voluntary sector. The regional MPCNs (implementation) Indicators of undiagnosed infection and new transmissions. Measures of ART uptake and effectiveness Measures of non ART treatment and care (to be decided). An appreciable reduction in the cost of ART to NHS Boards Needs assessment and service mapping by HIV Leads completed by March Assessment to be undertaken by Dec Three year MPCN plans drafted by June 2011 and finalised by Sept Procurement by April Plans implemented during n/a These actions will enable NHS Boards to understand the resources and developments required to address the needs of people living with HIV. The implementation of these actions will promote the optimal treatment and care of such individuals and will also lead to a potential reduction in the cost of ART for NHS Boards 24

25 Action Lead Responsibility Other Key Agencies Performance Indicators Short term Medium Term Long Term Outcomes 6. An investigation into the reasons why some people living with HIV do not attend specialist clinical services will be undertaken 7. Systems to monitor risk behaviours and new HIV infections among persons at highest risk of acquiring infection will be reviewed, developed and implemented. 8. The development and implementation of social marketing materials for MSM. 9. Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in MSM. Guidance will be implemented at the local and national level, where appropriate NHS Health Scotland Regional MPCNs Health Protection Scotland NHS Health Scotland (development and evaluation) Regional MPCNs (implementation) NHS Health Scotland (review and contribution) Regional MPCNs (implementation) Health Protection Scotland HIV Scotland in their role as representative of the HIV voluntary sector MRC Social and Public Health Sciences Unit (MRC SPHSU). NHS Health Scotland HIV Scotland in their role as representative of the HIV voluntary sector Scottish Government Regional MPCNs. MRC SPHSU and academic institutions. HIV Scotland in its role as representative of the HIV voluntary sector. The number of people with HIV who are not in contact with clinical or care services MPCNs satisfaction that sufficient information to inform decisionmaking is available An increased awareness amongst MSM around HIV prevention, diagnosis and transmission. An increase in access to interventions which are informed by best available evidence as reducing levels of HIV transmission among MSM. Investigation completed and recommendations drafted by March 2011 Review undertaken and completed by July The development of materials targeted at men who have sex with men by Dec Review of and contribution to guidance by Dec 2010 MPCNs to agree recommendations by September 2011 Development and implementation of systems by December 2011 Implementation of materials targeted at men who have sex with men by March Guidance to be implemented during MPCNs to implement recommendations by March 2012 n/a Evaluation of these materials in Further review of evidence in The findings will determine how to attract and retain in specialist clinical care those individuals who do not currently access services. An improved understanding of the epidemiology of HIV transmission and HIV related behaviour. The data will inform the planning of services and the development of guidance An increased awareness of existing and future evidence and guidance which will contribute to a reduction in the rate of new transmission of HIV among MSM and persons from areas of high prevalence, particularly African countries. 25

26 Action Lead Responsibility Other Key Agencies Performance Indicators Short Term Medium Term Long Term Outcomes 10. Measures will be taken to i) review and tailor (to national and local circumstances where appropriate) existing guidance and to ii) contribute to the development of new guidance on interventions to prevent and reduce HIV transmission in persons originating from areas high prevalence, particularly African countries. Guidance will be implemented at the local and national level, where appropriate. NHS Health Scotland (advice on contribution) MPCNs (implementation) MRC SPHSU and academic institutions. African health projects in voluntary sector. An increase in access to interventions which are informed by best available evidence as reducing levels of HIV transmission among persons originating from areas high prevalence, particularly African countries. Review of and contribution to guidance by Dec Guidance to be implemented during Further review of evidence in An increased awareness of existing and future evidence and guidance which will contribute to a reduction in the rate of new transmission of HIV among MSM and persons from areas of high prevalence, particularly African countries. 11. Educational activities for the HIV related workforce and Primary Care will be developed and implemented. NHS Education Scotland Regional MPCNs. Increased knowledge and its application in the HIV related workforce in preventing and reducing transmission of HIV. Needs assessment by March 2011, monitored through survey data. Delivery of training and education resources by Dec Education and training delivered by March The wider population, those at particular risk of infection and the HIV related workforce being informed, as appropriate, about current HIV knowledge, guidance and service availability. 26

27 Action Lead Responsibility Other Key Agencies Performance Indicators Short Term Medium Term Long Term Outcomes 12. Scottish Government will review existing budget spend and produce guidance on the recommended future spend of BBV budgets. NHS Boards will provide information on current and proposed future annual spend of the BBV Prevention budget against local priorities. 13. A National Programme Management approach will be employed to support the MPCNs. The Scottish Government, NHS Special Boards and other national agencies are responsible for delivering identified actions. Scottish Government Health Protection Scotland HIV Leads of NHS Boards Regional MPCNs Organisations and networks which have lead responsibility for the delivery of actions. Monitoring of the BBV prevention and diagnosis budget spend in line with Scottish Government guidance. Project management delivery of HIV Action Plan. BBV Prevention budget spend for 08/09 reviewed by Sept Performance management approach defined by Oct 2009 and process agreed by Dec Guidance will be issued to NHS Boards in Dec 2009 Establishment of APGB by April Report on previous year s spend by May of each year. Report on proposed future spend by January of each year. Implementation of Performance Management approach from Dec 09 March Improved budgetary accountability will lead to a more efficient use of funding. Accountability structures will ensure the actions are delivered efficiently, effectively and to timescale. 27